https://www.vrsurgeryonline.com/ is the single greatest resource for surgical retina fellows

Congratulations on matching to a fellowship in the most exciting field in ophthalmology!

Once the excitement wears off you might feel nervous - which is completely normal. Retina fellowship is like starting all over again. You’ll be seeing patients that you may have only had to superficially manage before and you’ll be doing surgeries that you’ve never done before.

But don’t worry. At every step of the way - you’ve managed to overcome the obstacles you needed to get to where you are, and retina fellowship will be no exception.

Here is a reading and resource roadmap that might help you get your bearings early on in fellowship.

During Residency

Big Picture: Focus on graduating. Enjoy the company of your co-residents. Enjoy not being stressed about matching.

1. Start reading https://retinatoday.com/. It’s a great resource to see what’s hot and being talked about in our field. Skim the headlines and read what’s interesting

2. Finish all the retina questions on the OKAPS question banks. You’ll pass OKAPS, you’ll pass the boards, and you’ll get some of the high yield topics.

3. Set up the VR surgery modules on the EyeSi (you might not have time in fellowship!) - play around to get a feel for the scope and the pedals. You don’t have to finish all the modules - just get a sense of what’s going on.

4. Read Vit Buckle Academy https://vba.vitbucklesociety.org/ it takes an hour to go through everything and get the basics.

5. Shadow some cases in the OR to get a sense of the steps involved in retinal surgery. How are retinal detachments repaired? What are the steps of a macular case? How is a scleral buckle done?

6. https://eyeguru.org/ has excellent modules for you to practice reading OCTs and fundus photos

During Fellowship

It’s time to start building the knowledge base.

1. Decide how you want to keep your notes organized. I recommend digital with a notetaking app. I like to use https://obsidian.md/ for my surgical notes/reading notes, apple notes for quick access sticky notes, and https://notability.com/ to store my textbooks that I annotate (it can let you sync PDFs with the cloud). All these things can be accessed on my desktop, laptop, and phone.

2. https://www.vrsurgeryonline.com/ is the single greatest retinal surgery resource ever created period. Read the chapters before your cases.

3. Study BCSC Retina and start being fluent in the wide variety of topics within the field. I would recommend a digital copy if you have one stored on the cloud.

4. Make a running list of topics that you want to learn about and look them up on - Eyewiki

5. Find the op-notes of the attendings you are working with and create your own library. This will be useful when you leave fellowship. I use it every day before the OR just to review the steps of surgery

A Deeper Dive (weekend Reads)

1. Review Articles on https://pubmed.ncbi.nlm.nih.gov/ are a great resource to get a summary of specific topics if Eyewiki isn’t in depth enough

2. The AAO preferred practice guidelines are an excellent benchmark to base your management on. https://www.aao.org/summary-benchmark-detail/retina-summary-benchmarks-2020

3. My favorite textbooks are Ryan’s Retina , Duker’s OCT, and the Yannuzzi Retina Atlas. If you are strapped on cash as a poor trainee - there are digital versions that may be able to be obtained until you buy your own copies as an attending.

4. Listen to podcasts http://www.retinapodcast.com/ and https://eyetube.net/podcasts/new-retina-radio during your commute

Continuing Medical Education

1. Download BrowZine https://browzine.com/ and follow the major journals. It uses your institution log in to automatically download the updated journal issues.

2. I created a website https://retinahomepage.com/ that tracks the latest free retina content that can be consumed.

3. Go to the major retina meetings. Vit Buckle Society, ASRS, and AAO are the ones that you can have access to early in training.

Parting thoughts

Don’t overwhelm yourself. Retina is a lifestyle - not a test that you have to cram for. As long as you maintain your curiosity and strive to be better for your patients - you will learn what you need to know in due time.

Good luck!!

Louie Cai

It’s been nearly 5 months since I’ve started, and i’ve finally found a moment to breathe after flying home for Thanksgiving. All in all, ophthalmology residency is everything I had hoped for and more. I previously said there was truly nowhere else I’d rather be, and I still believe that statement 120%.

In many ways, I’ve become more mature and confident, especially in my exam and my ability to explain “dry eye” syndrome to patients. However, in many other ways, I’m starting to finally grasp how large of a chasm that exists between me and where I need to be.

Anyways, this is a list of the top 10 things I wish I could have told myself when I started.

1. First and foremost, be a good person. You don’t have to be the world’s best doctor to make a positive impact on a patient’s life. Actually, you don’t even have to be a doctor to have a positive impact on another individual’s life. When you first start, you have no control over how much knowledge you have (minimal), your diagnostic accuracy (trace), or your ability to perform procedures well (nonexistent). You do, however, have complete control over the attitude and bedside manner you bring into the patient’s room. Likewise, you have the ability to make the patient encounter a positive one, even if you don’t have all the answers.

2. Seek out the uncomfortable. This is advice that was given to me by one of my favorite attendings. Residency is the time and place to feel uncomfortable, as there are seniors and attendings there to watch over you and save you should you make mistakes. Don’t shy away from doing procedures. Either do it now with someone watching or you’ll have to do it for the first time alone.

3. Just keep trying, even if you fail over and over. For the trickier aspects of the physical exam - scleral depression, gonioscopy, retinoscopy - it’s common knowledge that it will take time to master these skills. It’s important to keep attempting these techniques (in appropriate indications of course… ) and accepting that you will fail a lot. However, that doesn’t mean to be complacent with failure. You have to keep asking yourself, “why is this not working?,” “why is my view like this?” “what am I doing wrong?” It’s one thing to accidentally succeed and another to deliberately create the conditions for success. The former is not reproducible, the latter reflects actual mastery.

4. When things get hectic and you feel overwhelmed- stop, take a deep breath, and work on one task at a time, starting with the most important. This is advice for when things get crazy, either in the ER, on call, or in a busy clinic. No matter how many things you have to do, you can only finish one thing at at time, so you might as well do it well. Yes, everyone is having “an emergency,” but it is up to you to determine what are the the most critical things that will actually affect patient outcomes. And if you do those things in a prioritized order, there is nothing more you can do. This advice pertains more to the “feeling” of being overwhelmed. If you are actually overwhelmed with a certain situation, you should definitely call a senior.

5. Don’t reinvent the wheel. There have been residents for hundreds of years going through the same feelings and training experiences as you. Find people who are successful, and just copy them. This goes for exam techniques, how to perform certain steps in procedures, how to study, how to manage complex diseases — literally everything. While certainly there is room for innovation in medicine, when you are literally starting from the bottom, stick with the tried and true.

6. Don’t feel bad for what you can’t control (like wait times). I hate keeping patients waiting, and seeing 2, 3, or even 4 hour wait times in the ER gives me an enormous amounts of anxiety. There would be an overarching pressure to keep moving, and when I first started, I often felt like I was rushing through whatever I was doing in order to get to the next patient. However, this mindset actually helps nobody. It leads to a higher chance of delivering worse patient care to the patient you are currently with, which is ironic because this was the patient you were so worried about one encounter ago! You can only do one thing at a time, so do it well and do it efficiently

7. Don’t feel bad for what needs to be done! This goes for patients, particularly younger patients, who are very photophobic or can’t tolerate certain parts of the exam. In urgent situations, you have to examine the patient to determine the acuity of the problem. As long as the patient (or guardian) understands and has consented to the exam, it is your duty to perform the exam to the best of your ability even if it means causing discomfort or even in some instances, pain. You have to be the bad guy sometimes.

8. Be humble.. haha this is a more light hearted one. There are instances when a medical student will ask you something you don’t know (actually that’s most of the time for me) or even corrects you - and you can’t help but feel irked on the inside. Yes, you “should” know this and it certainly is unpleasant being corrected, but that negative feeling is a reflection of your ego/pride. In the end, the goal of our profession is to provide good patient care. Whether we are corrected by our attendings or our students should not matter.

9. Don’t let your work become routine. When treating dry eye or a corneal abrasion for the 100th time, it’s so easy to immediately start putting in the orders and typing the note. But now is not the time to feel like anything is routine, as we are complete beginners. This attitude will guarantee that you will miss the more uncommon diseases. Always have in the back of your mind, what else could it be? What more is there?

10. Lastly, and most importantly, go easy on yourself. You’re not as bad as you think you are, and you’ve come a long way.

Happy Thanksgiving!

Louie

During Episode 155 (LINK), Jay was joined by Dr. Jacque Duncan of the University of California San Francisco. One of the topics discussed was the Argus II prosthesis and how it can affect the quality of life of a patient. Today we are going to review how this device can help a patient with profound vision loss.

In retinal diseases like age-related macular degeneration and retinitis pigmentosa, retinal photoreceptors degenerate. Without these cells, light cannot be converted into electrical energy that transmits signals to the visual cortex and results in the ability to see. Artificial vision aims to restore sight by electrically stimulating the retina. Interestingly, the idea of artificial vision began in 1752 when Benjamin Franklin theorized that the use of electricity could restore vision. In 1755 a French scientist named Charles Leroy tested this theory by applying electrical current across the ocular surface to a blind volunteer that reportedly saw flashes of light. As the fields of microelectronics and vitreo-retinal surgery developed, research into devices that could potentially restore vision began.  

 The Argus II prosthesis is an epiretinal implant designed to replace photoreceptor function. It consists of an implanted unit and an external one worn by the user. The internal unit is composed of 60 individual electrodes arranged in a rectangular array (Figure 1) that receives power and data from the external unit.

 Figure 1

Image Credit: https://journals.lww.com/internat-ophthalmology/fulltext/2016/05640/The_Argus_II_Retinal_Prosthesis___A_Comprehensive.4.aspx

 The external unit has a camera mounted on a pair of glasses, with a video processing unit and battery (Figure 2). The system works by capturing a scene with the camera, that is then analyzed by the video processing unit, which transfers electronic data to the electrode array to stimulate retinal cells.

 Figure 2

Image Credit: https://journals.lww.com/internat-ophthalmology/fulltext/2016/05640/The_Argus_II_Retinal_Prosthesis___A_Comprehensive.4.aspx

This device provides a new type of visual stimulation so it is important for patients to understand what they will be able to see after implantation. While they will not (yet) be able to read, drive, or recognize faces, the use of this prosthesis will allow them to localize objects and identify movements. To determine how the use of this prosthesis changed the quality of life of patients FLORA, or Functional Low-Vision Observer Rated Assessment, was developed. This survey reported that no patients experienced a negative effect, and after 1 year of use 80% of patients reported a positive impact.

 Argus II is just one of the devices being studied for the restoration of vision. The field of artificial vision is rapidly advancing, and different kind of prosthesis are currently under development. Groups have demonstrated that some vision restoration is already possible, while continuing to work to improve the results. Simultaneously, other modalities like genetic therapy are being studied to achieve the same goal. It will be interesting to see how and if separate therapies can work together to restore functional vision.

     -Amy Kloosterboer

During Episode 154 (LINK), Jay was joined by Drs. Ajay Kuriyan and David Ehmann to discuss phacovitrectomy. One of the tools utilized for assessment prior to this surgery is an A-scan which is also known as an amplitude scan ultrasound biometry. This technique was first used by Mudnt and Hughes in 1956 and is routinely used in ophthalmology today. It is used to measure the anterior chamber depth, axial length, and lens thickness by using ultrasound technology. In an A-scan, sound travels through the eye encountering different kinds of media. A probe that emits a single sound beam is placed on the tear film, which due to its properties can be used for transmission of the beam into the eye. It first travels through the solid cornea, the liquid aqueous, the solid lens, the liquid vitreous, the solid retina, choroid, sclera, and then orbital tissue. The location in which media of different densities meet is called the interface. It is at this junction that an echo is created when the sound beam strikes the interface and bounces back into the probe tip. The echoes that are returned to this probe are converted into a series of spikes that have a height proportional to the strength of the echo, as seen in the figure below.

Image Credit: https://www.cehjournal.org/article/caring-for-a-and-b-scans/

The difference in height of each spike is created by the difference between the two media at each interface. The larger the difference, the taller the spike will appear. A weak spike corresponds to a weak echo due to a lack of difference between two media at the interface. If the two media the sound beam is passing through have identical densities, then no spike will be recorded during the A-scan. The figure shown below represents a normal eye, but if for example, a cataract was present then the central lens area would display spikes of different heights as the sound beam travels though differing densities within the lens nucleus.

Image Credit: https://eyewiki.aao.org/Ophthalmologic_Ultrasound#A-Scan

Lastly, it is important to know that there are several factors that can influence the height of the spikes recorded. The angle at which the sound beam hits the interface will determine how strongly the echo is received. The probe should be held in such a way that the sound beam strikes the structures of the eye at a perpendicular angle. If the transducer is held such that the angle of incidence is higher, some echoes will not return to the transducer, therefore no spike will be recorded. The smoothness and the regularity of the interface the sound is traveling through will also affect the echo. Irregularities can cause reflection and refraction of sound beams, and an increase in density will absorb more energy and cause the signal’s amplitude to decrease in height.

     -Amy Kloosterboer

                For Episode 153 (LINK), Jay was joined by the Physician on FIRE (Financial Independence and Retire Early) to discuss topics important to a physician managing his or her finances. As a fourth-year medical student about to enter my internship and ophthalmology residency, my initial thoughts were that I was still years away from the chance to apply these lessons to myself. However, as my world prepares to shift from tuition payments to monthly income, from loan disbursement to loan repayment, I recently began to realize the importance of my own financial education. With little training outside of one high school course in macroeconomics, I started simple by visiting www.physicianonfire.com, reading the classic White Coat Investor book by James M. Dahle, and discussing lessons learned with friends. To me, the importance of “FIRE” is less of the “Retire Early” and more of the “INDEPENDENCE” – the ability to choose what you want to do, where, how much, and for how long.

                At the beginning of the episode, Jay remarked that there is often a sort of hesitation to discuss finances within medicine. “If you’re doing this for the money,” it is often stated, “then you’re not doing it for the patient and you’re doing it for the wrong reason.” Although there certainly are important lessons behind these adages, that does not mean that we should be unprepared for financial decisions to come. At the end of the day, there will come a time for every physician where his or her financial situation changes – be that anything from graduating residency, to repayment of loans, to starting a family, to health issues, to retirement. We are all at different points in our respective journeys, but it behooves us to try understand more every day. In my reading, the White Coat Investor called out a quote by Dave Ramsey that stuck out to me: “If you will live like no one else, later you can live like no one else.” To me, this quote has implications outside of the financial realm, as well. Medicine is a field of “lifelong learning” with years of training, steep learning curves, and ever-innovating therapies. All of us began our journeys with a desire to help change the lives of our patients, and we are constantly striving to do better and to be better. At this point, it is impossible to know exactly where my career will take me; however, I do know that I would like the opportunity to continue pursuing my passion from beginning to end. And to me, the “independence” aspect of FIRE seems like one way to help make this happen.

- Michael Venincasa